Expert pearls in cataract surgery after penetrating keratoplasty

Cataract surgery following penetrating keratoplasty (PKP) presents a unique set of challenges, requiring a careful balance between preserving graft integrity and achieving meaningful visual improvement.

In this expert pearl, Prof. Dr Suphi Taneri shares his practical approach to managing these complex cases, from preoperative assessment and biometry to surgical technique and postoperative care.

In eyes with a previous PKP, I approach cataract surgery as a procedure in which graft protection and refractive realism are equally important. Preoperatively, I want to know whether the graft is clear and stable, whether the endothelium is likely to tolerate phaco, and whether the cornea is sufficiently regular to allow meaningful measurements. I therefore pay particular attention to graft clarity, prior rejection history, pachymetry, endothelial reserve if specular microscopy is available, wound integrity, peripheral thinning, ocular surface quality, glaucoma, and steroid response. I also prefer to operate only once the graft is quiet and keratometric measurements have stabilized, ideally after all sutures have been removed.

In the informed-consent process, I make a point of setting realistic expectations. I explain that the goal is to improve vision safely, not to promise refractive perfection. Visual recovery may be slower than in routine cataract surgery, refractive predictability is lower, and postoperative correction with spectacles, rigid or scleral lenses, or later refractive enhancement may still be required. I also make it clear that cataract surgery places additional stress on a transplanted cornea and carries a low but definite risk of persistent edema, rejection, or late endothelial failure.

I only finalize IOL planning once the graft is quiet and the measurements are reproducible. If the graft is clear, I prefer optical biometry; otherwise, ultrasound remains valuable. For corneal power, I do not rely on a single reading. In my practice, I compare tomography and OCT-derived keratometry, because in these eyes agreement across technologies is often more informative than any single device output. Swept-source OCT platforms are useful, especially because they can add total-keratometry information, but I use OCT keratometry as part of a composite assessment rather than as a stand-alone truth.

For IOL choice, I still favor a monofocal lens in most post-PKP eyes. If the astigmatism is regular, stable, and consistently measured after suture removal, a toric IOL may be appropriate. If the graft is optically irregular, however, I prefer to be conservative and to think of the cataract procedure as the first refractive step, not necessarily the last. In selected cases with irregular optics, higher-order aberrations, or troublesome stray peripheral light, I also consider small-aperture optics. The IC-8 Apthera (Bausch + Lomb) is attractive in this context because the pinhole principle can reduce the functional impact of peripheral aberrated rays and stray-light while improving depth of focus. We have also recently published our own results with the IC-8 in a book chapter edited by Jorge L Alió.

In pseudophakic eyes with persistent optical-quality problems, I also keep supplementary pinhole optics in mind. The XtraFocus (Morcher) established the principle of a non-refractive pinhole implant for irregular corneas, including post-PKP eyes. More recently, a newer non-refractive small-aperture mask, VisionXtender (Morcher), has been introduced as a supplementary optic placed in front of the primary IOL. I see these small-aperture strategies as niche but very interesting options when the main problem is not only spherical error, but also optical quality.

My operative strategy is straightforward: I try to keep trauma away from both the graft-host junction and the endothelium. I inspect the host rim and peripheral cornea carefully and choose the incision site accordingly. If the graft is large, the host rim is narrow, the peripheral cornea is thinned, or I am concerned about wound architecture, I prefer a limbal or scleral approach rather than a routine clear corneal incision, and I have a low threshold for suturing the wound.

For endothelial protection, I use the soft-shell technique. I first coat the endothelium with a dispersive OVD and then inject a cohesive OVD to create and maintain space, so that a protective layer remains over the graft endothelium throughout the case. Beyond that, I try to minimize phaco energy, reduce fluidic turbulence, work deeper in the chamber, and avoid bringing nuclear fragments toward the cornea. In eyes with borderline endothelial reserve and a dense nucleus, I also think carefully about whether prolonged phaco is really the least traumatic option, since endothelial loss after phaco is known to be greater in post-PK eyes, and older data suggest that ECCE may still be worth considering in selected hard nuclei.

Postoperatively, I am more protective than I am in routine cataract cases. I usually maintain or intensify topical steroid coverage, taper more cautiously, and monitor the graft closely for persistent edema, keratic precipitates, anterior chamber reaction, and early signs of rejection. I also check IOP early and repeatedly, because these eyes are vulnerable both to postoperative pressure spikes and to steroid response. In my view, postoperative care in these patients is not routine pseudophakic follow-up; it is continued graft surveillance.

From a refractive standpoint, I only reassess once the cornea is quiet and stable. If there is residual ametropia, I move in stages: spectacles first, then rigid or scleral lenses if irregularity is limiting quality of vision, and finally refractive fine-tuning if the eye remains stable. That fine-tuning may take place months later, and in selected eyes even many years later, provided the graft remains healthy. Options include PRK, selected femto-LASIK in carefully chosen cases, arcuate keratotomy for regular residual astigmatism, and supplementary/add-on IOLs when the cornea is not an ideal laser candidate or when the residual error is larger. In post-keratoplasty pseudophakia, sulcus-fixated supplementary IOLs are a particularly elegant option because they preserve the primary IOL and can correct residual spherical and astigmatic error without reopening the capsular bag.

Useful resources

• Nagra PK, Rapuano CJ, Laibson PR, et al. Cataract extraction following penetrating keratoplasty. Cornea. 2004;23:377-379.
• Acar BT, Utine CA, Acar S, Ciftci F. Endothelial cell loss after phacoemulsification in eyes with previous penetrating keratoplasty, previous deep anterior lamellar keratoplasty, or no previous surgery.J Cataract Refract Surg.2011;37:2013-2017.
• Kim EC, Byun YS, Kim MS. A comparison of endothelial cell loss after phacoemulsification in penetrating keratoplasty patients and normal patients. Ophthalmologica. 2010;224:366-370.
• Miyata K, Nagamoto T, Maruoka S, et al. Efficacy and safety of the soft-shell technique in cases with a hard lens nucleus. J Cataract Refract Surg. 2002;28:1546-1550.
• Oh R, Oh JY, Choi HJ, Kim MK, Yoon CH. Comparison of ocular biometric measurements in patients with cataract using three swept-source optical coherence tomography devices. BMC Ophthalmol. 2021;21:62.
• Meyer JJ, McGhee CNJ. Supplementary, sulcus-fixated intraocular lens in the treatment of spherical and astigmatic refractive errors in pseudophakic eyes after keratoplasty. Cornea. 2015;34:1052-1056.
• Shajari M, Mackert M, Langer J, et al. Safety and efficacy of a small-aperture capsular bag-fixated intraocular lens in eyes with severe corneal irregularities. J Cataract Refract Surg. 2020;46:188-192.
• Franco F, Branchetti M, Vicchio L, et al. Implantation of a small aperture intraocular lens in eyes with irregular corneas and higher order aberrations. J Ophthalmic Vis Res. 2022;17:317-323.
• Trindade CC, Trindade BC, Trindade FC, Werner L, Osher RH, Santhiago MR. New pinhole sulcus implant for the correction of irregular corneal astigmatism. J Cataract Refract Surg. 2017;43:1297-1306.
• Ho VWM, Chan E, Yuen HKL, et al. One-year visual outcome of secondary piggyback pinhole device implantation in pseudophakic eyes with irregular corneal astigmatism and iris trauma. Eye (Lond). 2021;35:1171-1178.
• Schultz T, Dick HB, Gerste RD, et al. A new small-aperture device implanted on top of the intraocular lens: safety, feasibility, and first clinical results. J Refract Surg. 2024;40:e662-e666.
• dos Santos Forseto A, Nosé W, Nosé RM. Photorefractive keratectomy with mitomycin C after keratoplasty. J Refract Surg. 2010;26:189-195.
• Donoso R, Hernández M, Martínez L, et al. Long-term results of LASIK refractive error correction after penetrating keratoplasty in patients with keratoconus. Arch Soc Esp Oftalmol. 2015;90:308-311.
• Huang PYC, Lai JSM, Leung ATS, Chan W-M. Laser-assisted subepithelial keratectomy and photorefractive keratectomy in the treatment of astigmatism after penetrating keratoplasty. J Cataract Refract Surg.2011;37:909-914.
• Bayramlar H, Karadag R, Cakici O, Ozsoy I. Arcuate keratotomy on post-keratoplasty astigmatism is unpredictable and frequently needs repeat procedures to increase its success rate. Br J Ophthalmol. 2016;100:757-761.

Disclosures: Prof. Dr Taneri has nothing to disclose in relation to this article. No fees or funding were associated with this article.

Citation: Suphi Taneri. Expert pearls in cataract surgery after penetrating keratoplasty. touchOPHTHALMOLOGY.com. March 24, 2026.

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